Does increased implementation support improve community clinics' guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial

Rachel Gold, Arwen Bunce, Stuart Cowburn, James V Davis, Joan C Nelson, Christine A Nelson, Elisabeth Hicks, Deborah J Cohen, Michael A Horberg, Gerardo Melgar, James W Dearing, Janet Seabrook, Ned Mossman, Joanna Bulkley, Rachel Gold, Arwen Bunce, Stuart Cowburn, James V Davis, Joan C Nelson, Christine A Nelson, Elisabeth Hicks, Deborah J Cohen, Michael A Horberg, Gerardo Melgar, James W Dearing, Janet Seabrook, Ned Mossman, Joanna Bulkley

Abstract

Background: Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs).

Methods: This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs' EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes.

Results: Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes.

Conclusions: Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics' ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs.

Trial registration: ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

Keywords: Community health centers; Guideline-concordant care; Implementation support.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Study flow timeline
Fig. 2
Fig. 2
Statin prescribing by month and study arm
Fig. 3
Fig. 3
ACE/ARB prescribing by month and study arm

References

    1. Rapport F, Clay-Williams R, Churruca K, Shih P, Hogden A, Braithwaite J. The struggle of translating science into action: foundational concepts of implementation science. J Eval Clin Pract. 2018;24(1):117–126. doi: 10.1111/jep.12741.
    1. Mendel P, Meredith LS, Schoenbaum M, Sherbourne CD, Wells KB. Interventions in organizational and community context: a framework for building evidence on dissemination and implementation in health services research. Adm Policy Ment Health. 2008;35(1-2):21–37. doi: 10.1007/s10488-007-0144-9.
    1. Powell BJ, McMillen JC, Proctor EK, Carpenter CR, Griffey RT, Bunger AC, et al. A compilation of strategies for implementing clinical innovations in health and mental health. Med Care Res Rev. 2012;69(2):123–157. doi: 10.1177/1077558711430690.
    1. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci. 2013;8:139. doi: 10.1186/1748-5908-8-139.
    1. Weiner BJ, Rohweder CL, Scott JE, Teal R, Slade A, Deal AM, et al. Using practice facilitation to increase rates of colorectal cancer screening in community health centers, North Carolina, 2012-2013: Feasibility, Facilitators, and Barriers. Prev Chronic Dis. 2017;14:E66. doi: 10.5888/pcd14.160454.
    1. Coronado GD, Schneider JL, Petrik A, Rivelli J, Taplin S, Green BB. Implementation successes and challenges in participating in a pragmatic study to improve colon cancer screening: perspectives of health center leaders. Transl Behav Med. 2017;7(3):557–566. doi: 10.1007/s13142-016-0461-1.
    1. Gold R, Nelson C, Cowburn S, Bunce A, Hollombe C, Davis J, et al. Feasibility and impact of implementing a private care system's diabetes quality improvement intervention in the safety net: a cluster-randomized trial. Implement Sci. 2015;10(1):83. doi: 10.1186/s13012-015-0259-4.
    1. James AS, Richardson V, Wang JS, Proctor EK, Colditz GA. Systems intervention to promote colon cancer screening in safety net settings: protocol for a community-based participatory randomized controlled trial. Implement Sci. 2013;8:58. doi: 10.1186/1748-5908-8-58.
    1. Mader EM, Fox CH, Epling JW, Noronha GJ, Swanger CM, Wisniewski AM, et al. A practice facilitation and academic detailing intervention can improve cancer screening rates in primary care safety net clinics. J Am Board Fam Med. 2016;29(5):533–542. doi: 10.3122/jabfm.2016.05.160109.
    1. Chaple M, Sacks S, Randell J, Kang B. A technical assistance framework to facilitate the delivery of integrated behavioral health services in Federally Qualified Health Centers (FQHCs) J Subst Abuse Treat. 2016;60:62–69. doi: 10.1016/j.jsat.2015.08.006.
    1. Quinonez RB, Consky E, Mattison K, Randolph G. Using quality improvement methods to implement an early childhood oral health initiative: a Federally Qualified Health Center Pilot Study. J Clin Pediatr Dent. 2017;41(5):351–357. doi: 10.17796/1053-4628-41.5.351.
    1. Baker DW, Brown T, Buchanan DR, Weil J, Balsley K, Ranalli L, et al. Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: a randomized clinical trial. JAMA Intern Med. 2014;174(8):1235–1241. doi: 10.1001/jamainternmed.2014.2352.
    1. Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol. 2008;41(3-4):327–350. doi: 10.1007/s10464-008-9165-0.
    1. Rohrbach LA, Gunning M, Sun P, Sussman S. The project towards no drug abuse (TND) dissemination trial: implementation fidelity and immediate outcomes. Prev Sci. 2010;11(1):77–88. doi: 10.1007/s11121-009-0151-z.
    1. van de Steeg-van Gompel CH, Wensing M, De Smet PA. Implementation of adherence support for patients with hypertension despite antihypertensive therapy in general practice: a cluster randomized trial. Am J Hypertens. 2010;23(9):1038–1045. doi: 10.1038/ajh.2010.63.
    1. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65–76. doi: 10.1007/s10488-010-0319-7.
    1. Dickinson WP, Dickinson LM, Nutting PA, Emsermann CB, Tutt B, Crabtree BF, et al. Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial. Ann Fam Med. 2014;12(1):8–16. doi: 10.1370/afm.1591.
    1. Lincoln Y, Guba EG. Naturalistic inquiry. Newberry Park, CA: Sage; 1985.
    1. Mitchell SG, Schwartz RP, Kirk AS, Dusek K, Oros M, Hosler C, et al. SBIRT Implementation for adolescents in urban Federally Qualified Health Centers. J Subst Abuse Treat. 2016;60:81–90. doi: 10.1016/j.jsat.2015.06.011.
    1. Rycroft-Malone J, Seers K, Eldh AC, Cox K, Crichton N, Harvey G, et al. A realist process evaluation within the Facilitating Implementation of Research Evidence (FIRE) cluster randomised controlled international trial: an exemplar. Implement Sci. 2018;13(1):138. doi: 10.1186/s13012-018-0811-0.
    1. Seers K, Rycroft-Malone J, Cox K, Crichton N, Edwards RT, Eldh AC, et al. Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Implement Sci. 2018;13(1):137. doi: 10.1186/s13012-018-0831-9.
    1. Gold R, Hollombe C, Bunce A, Nelson C, Davis JV, Cowburn S, et al. Study protocol for “Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET)”: a pragmatic trial comparing implementation strategies. Implement Sci. 2015;10:144.
    1. Cohen D, McDaniel RR, Jr, Crabtree BF, Ruhe MC, Weyer SM, Tallia A, et al. A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004;49(3):155–168. doi: 10.1097/00115514-200405000-00005.
    1. Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med. 2012;43(3):337–350. doi: 10.1016/j.amepre.2012.05.024.
    1. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8 Suppl 2):II2–I45.
    1. Forsetlund L, Bjorndal A, Rashidian A, Jamtvedt G. O‘Brien MA, Wolf F, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database SystRev. 2009;2:CD003030.
    1. Yamada J, Shorkey A, Barwick M, Widger K, Stevens BJ. The effectiveness of toolkits as knowledge translation strategies for integrating evidence into clinical care: a systematic review. BMJ Open. 2015;5(4):e006808. doi: 10.1136/bmjopen-2014-006808.
    1. Walsh J, McDonald KM, Shojania KG, Sundaram V, Nayak S, Davies S, et al. Closing the quality gap: a critical analysis of quality improvement strategies (Vol. 3: Hypertension Care). NBK43920 bookaccession. 2005.
    1. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10(1):63–74. doi: 10.1370/afm.1312.
    1. Parchman ML, Noel PH, Culler SD, Lanham HJ, Leykum LK, Romero RL, et al. A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects. Implement Sci. 2013;8:93. doi: 10.1186/1748-5908-8-93.
    1. Chan WV, Pearson TA, Bennett GC, Cushman WC, Gaziano TA, Gorman PN, et al. ACC/AHA special report: clinical practice guideline implementation strategies: a summary of systematic reviews by the NHLBI implementation science work group: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(9):e122–ee37. doi: 10.1161/CIR.0000000000000481.
    1. Irwin R, Stokes T, Marshall T. Practice-level quality improvement interventions in primary care: a review of systematic reviews. Primary health care research & development. 2015;16(6):556–577. doi: 10.1017/S1463423615000274.
    1. Mostofian F, Ruban C, Simunovic N, Bhandari M. Changing physician behavior: what works? Am J Manag Care. 2015;21(1):75–84.
    1. Creswell J, Plano CV. Designing and conducting mixed methods research. Thousand Oaks, CA: Sage; 2007.
    1. Jaen CR, Crabtree BF, Palmer RF, Ferrer RL, Nutting PA, Miller WL, et al. Methods for evaluating practice change toward a patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1):S9–20. doi: 10.1370/afm.1108.
    1. Nutting PA, Crabtree BF, Stewart EE, Miller WL, Palmer RF, Stange KC, et al. Effect of facilitation on practice outcomes in the National Demonstration Project model of the patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1):S33–S44. doi: 10.1370/afm.1119.
    1. Helfrich CD, Li YF, Sharp ND, Sales AE. Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implement Sci. 2009;4:38. doi: 10.1186/1748-5908-4-38.
    1. Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;34(5 Pt 2):1189–1208.
    1. Zhou H, Taber C, Arcona S, Li Y. Difference-in-differences method in comparative effectiveness research: utility with unbalanced groups. Appl Health Econ Health Policy. 2016;14(4):419–429. doi: 10.1007/s40258-016-0249-y.
    1. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–706. doi: 10.1093/aje/kwh090.
    1. Borkan J. Immersion/crystallization. In: Crabtree BF, Miller WL, editors. Doing qualitative research. 2. Thousand Oaks, CA: Sage Publications, Inc.; 1999. pp. 179–194.
    1. Boeije Hennie. Quality and Quantity. 2002;36(4):391–409. doi: 10.1023/A:1020909529486.
    1. Collins GS, Altman DG. External validation of QDSCORE((R)) for predicting the 10-year risk of developing Type 2 diabetes. Diabet Med. 2011;28(5):599–607. doi: 10.1111/j.1464-5491.2011.03237.x.
    1. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11:72. doi: 10.1186/s13012-016-0437-z.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi: 10.1186/1748-5908-4-50.
    1. Lanham HJ, Leykum LK, Taylor BS, McCannon CJ, 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.
    1. Cilenti D, Brownson RC, Umble K, Erwin PC, Summers R. Information-seeking behaviors and other factors contributing to successful implementation of evidence-based practices in local health departments. J Public Health Manag Pract. 2012;18(6):571–576. doi: 10.1097/PHH.0b013e31825ce8e2.
    1. Fretheim A, Flottorp S, Oxman A. NIPH systematic reviews: executive summaries. Effect of interventions for implementing Clinical Practice Guidelines. Oslo. Norway: Knowledge Centre for the Health Services at The Norwegian Institute of Public Health (NIPH), Copyright (c)2015 by The Norwegian Institute of Public Health (NIPH). 2015.
    1. Flodgren G, Hall AM, Goulding L, Eccles MP, Grimshaw JM, Leng GC, et al. Tools developed and disseminated by guideline producers to promote the uptake of their guidelines. Cochrane Database Syst Rev. 2016;8:CD010669.
    1. Watkins K, Wood H, Schneider CR, Clifford R. Effectiveness of implementation strategies for clinical guidelines to community pharmacy: a systematic review. Implement Sci. 2015;10:151. doi: 10.1186/s13012-015-0337-7.
    1. Sohn W, Ismail AI, Tellez M. Efficacy of educational interventions targeting primary care providers' practice behaviors: an overview of published systematic reviews. J Public Health Dent. 2004;64(3):164–172. doi: 10.1111/j.1752-7325.2004.tb02747.x.
    1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–1230. doi: 10.1016/S0140-6736(03)14546-1.
    1. Herbert CP, Wright JM, Maclure M, Wakefield J, Dormuth C, Brett-MacLean P, et al. Better prescribing project: a randomized controlled trial of the impact of case-based educational modules and personal prescribing feedback on prescribing for hypertension in primary care. Fam Pract. 2004;21(5):575–581. doi: 10.1093/fampra/cmh515.
    1. Desveaux L, Saragosa M, Rogers J, Bevan L, Loshak H, Moser A, et al. Improving the appropriateness of antipsychotic prescribing in nursing homes: a mixed-methods process evaluation of an academic detailing intervention. Implement Sci. 2017;12(1):71. doi: 10.1186/s13012-017-0602-z.
    1. O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database SystRev. 2007;4:CD000409.
    1. Berta W, Cranley L, Dearing JW, Dogherty EJ, Squires JE, Estabrooks CA. Why (we think) facilitation works: insights from organizational learning theory. Implement Sci. 2015;10:141. doi: 10.1186/s13012-015-0323-0.
    1. Wang A, Pollack T, Kadziel LA, Ross SM, McHugh M, Jordan N, et al. Impact of practice facilitation in primary care on chronic disease care processes and outcomes: a systematic review. J Gen Intern Med. 2018;33(11):1968–1977. doi: 10.1007/s11606-018-4581-9.
    1. Ostini R, Hegney D, Jackson C, Williamson M, Mackson JM, Gurman K, et al. Systematic review of interventions to improve prescribing. Ann Pharmacother. 2009;43(3):502–513. doi: 10.1345/aph.1L488.
    1. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6:CD000259.
    1. Jamtvedt G, Young JM, Kristoffersen DT. Thomson O‘Brien MA. Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database SystRev. 2003;3:CD000259.
    1. Hysong SJ. Meta-analysis: audit and feedback features impact effectiveness on care quality. Med Care. 2009;47(3):356–363. doi: 10.1097/MLR.0b013e3181893f6b.
    1. Ivers NM, Grimshaw JM, Jamtvedt G, Flottorp S. O‘Brien MA, French SD, et al. Growing literature, stagnant science? Systematic review, meta-regression and cumulative analysis of audit and feedback interventions in health care. J Gen Intern Med. 2014;29(11):1534–1541. doi: 10.1007/s11606-014-2913-y.
    1. Bell BS, Tannenbaum SI, Ford JK, Noe RA, Kraiger K. 100 years of training and development research: what we know and where we should go. Journal of Applied Psychology. 2017;102(3):305. doi: 10.1037/apl0000142.
    1. Wensing M. The Tailored Implementation in Chronic Diseases (TICD) project: introduction and main findings. Implement Sci. 2017;12(1):5. doi: 10.1186/s13012-016-0536-x.
    1. Powell BJ, Beidas RS, Lewis CC, Aarons GA, McMillen JC, Proctor EK, et al. Methods to improve the selection and tailoring of implementation strategies. J Behav Health Serv Res. 2017;44(2):177–194. doi: 10.1007/s11414-015-9475-6.
    1. Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, et al. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev. 2015(4):Cd005470.
    1. Stirman SW, Gamarra J, Bartlett B, Calloway A, Gutner C. Empirical examinations of modifications and adaptations to evidence-based psychotherapies: methodologies, impact, and future directions. Clin Psychol (New York). 2017;24(4):396–420.
    1. Ovretveit John, Dolan-Branton Lisa, Marx Michael, Reid Amy, Reed Julie, Agins Bruce. Adapting improvements to context: when, why and how? International Journal for Quality in Health Care. 2018;30(suppl_1):20–23. doi: 10.1093/intqhc/mzy013.
    1. Thies K, Anderson D, Cramer B. Lack of adoption of a mobile app to support patient self-management of diabetes and hypertension in a federally qualified health center: interview analysis of staff and patients in a failed randomized trial. JMIR human factors. 2017;4(4):e24. doi: 10.2196/humanfactors.7709.
    1. Liberati EG, Ruggiero F, Galuppo L, Gorli M, Gonzalez-Lorenzo M, Maraldi M, et al. What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation. Implement Sci. 2017;12(1):113. doi: 10.1186/s13012-017-0644-2.
    1. Vandenberg AE, Vaughan CP, Stevens M, Hastings SN, Powers J, Markland A, et al. Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use. Int J Qual Health Care. 2017;29(1):117–123.
    1. Moja L, Liberati EG, Galuppo L, Gorli M, Maraldi M, Nanni O, et al. Barriers and facilitators to the uptake of computerized clinical decision support systems in specialty hospitals: protocol for a qualitative cross-sectional study. Implement Sci. 2014;9:105. doi: 10.1186/s13012-014-0105-0.
    1. Berwick DM. Disseminating innovations in health care. Jama. 2003;289(15):1969–1975. doi: 10.1001/jama.289.15.1969.

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