A real-world stepped wedge cluster randomized trial of practice facilitation to improve cardiovascular care

Clare Liddy, William Hogg, Jatinderpreet Singh, Monica Taljaard, Grant Russell, Catherine Deri Armstrong, Ayub Akbari, Simone Dahrouge, Jeremy M Grimshaw, Clare Liddy, William Hogg, Jatinderpreet Singh, Monica Taljaard, Grant Russell, Catherine Deri Armstrong, Ayub Akbari, Simone Dahrouge, Jeremy M Grimshaw

Abstract

Background: Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC's impact on adherence to processes of care delivery.

Methods: A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada (ClinicalTrials.gov: NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention.

Results: Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively.

Conclusions: IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice.

Trial registration: ClinicalTrials.gov NCT00574808.

Figures

Fig. 1
Fig. 1
IDOCC stepped wedge study design. Shaded cells represent intervention periods. Blank cells represent control periods
Fig. 2
Fig. 2
Observed mean adherence score (%) over time in practices allocated to study steps, indicating year of implementation of the intervention
Fig. 3
Fig. 3
Estimated effect of the IDOCC intervention presented as adjusted mean adherence score (%) averaged over all practices in control, intensive, and sustainability conditions. The model assumes a single underlying secular trend across steps and estimates a shift in level as a result of the intervention. Solid lines represent time intervals with observed data in that condition; dashed lines represent time intervals with no observed data in that condition

References

    1. Knox L, Taylor EF, Geonnotti K, Machta R, Kim J, Nysenbaum J, et al. Developing and running a primary care practice facilitation program: a how-to guide. Agency for Healthcare Research and Quality. 2011. . Accessed 7 May 2015.
    1. Hogg W, Lemelin J, Moroz I, Soto E, Russell G. Improving prevention in primary care: evaluating the sustainability of outreach facilitation. Can Fam Physician. 2008;54(5):712–20.
    1. Kottke TE, Solberg LI, Brekke ML, Conn SA, Maxwell P, Brekke MJ. A controlled trial to integrate smoking cessation advice into primary care practice: Doctors Helping Smokers Round III. J Fam Pract. 1992;34(6):701–8.
    1. Dietrich AJ, O’Connor GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention. A community practice randomized trial. BMJ. 1992;304(6828):687–91. doi: 10.1136/bmj.304.6828.687.
    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. Hogg W, Baskerville N, Lemelin J. Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis. BMC Health Serv Res. 2005;5(1):20. doi: 10.1186/1472-6963-5-20.
    1. McCowan C, Neville RG, Crombie IK, Clark RA, Warner FC. The facilitator effect: results from a four-year follow-up of children with asthma. Br J Gen Pract. 1997;47(416):156–60.
    1. Roetzheim RG, Christman LK, Jacobsen PB, Schroeder J, Abdulla R, Hunter S. Long-term results from a randomized controlled trial to increase cancer screening among attendees of community health centers. Ann Fam Med. 2005;3(2):109–14. doi: 10.1370/afm.240.
    1. Crabtree BF, Nutting PA, Miller WL, Strange KC, Stewart EE, Jaén CR. Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Ann Fam Med. 2010;8(Suppl 1):S80–90. doi: 10.1370/afm.1107.
    1. Liddy C, Hogg W, Russell G, Wells G, Armstrong CD, Akbari A, et al. Improved Delivery of Cardiovascular Care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomized controlled trial in primary care. Implement Sci. 2011;6:110. doi: 10.1186/1748-5908-6-110.
    1. Campbell MK, Piaggio G, Elbourne DR, Altman DG, CONSORT Group Consort 2010 statement: extension to cluster randomized trials. BMJ. 2012;345:e5661. doi: 10.1136/bmj.e5661.
    1. Bains N, Dall K, Hay C, Pacey M, Sarkella J, Ward M. Population health profile: Champlain LHIN. . Accessed 7 May 2015.
    1. Brown CA, Lilford RJ. The stepped wedge trial design: a systematic review. BMC Med Res Methodol. 2006;6:54. doi: 10.1186/1471-2288-6-54.
    1. Esri. What is GIS? . Accessed 13 Feb 2015.
    1. The College of Physicians and Surgeons of Ontario. All doctors search. . Accessed 19 May 2015.
    1. Borgiel AE, Dunn EV, Lamont CT, MacDonald PJ, Evensen MK, Bass MJ, et al. Recruiting family physicians as participants in research. Fam Pract. 1989;6(3):168–72. doi: 10.1093/fampra/6.3.168.
    1. Institute for Healthcare Improvement. Science of improvement: testing changes. . Updated 2014. Accessed 13 Feb 2015.
    1. Liddy C, Wiens M, Hogg W. Methods to achieve high interrater reliability in data collection from primary care medical records. Ann Fam Med. 2011;9(1):57–62. doi: 10.1370/afm.1195.
    1. Ramsden VR, Campbell V, Boechler B, Blau J, Berscheid Y. Strategies to stroke prevention: nurse facilitation. Concern. 1994;23(6):22–3.
    1. Woertman W, de Hoop E, Moerbeek M, Zuidema SU, Gerritsen DL, Teerenstra S. Stepped wedge designs could reduce the required sample size in cluster randomized trials. J Clin Epidemiol. 2013;66(7):752–8. doi: 10.1016/j.jclinepi.2013.01.009.
    1. Hussey MA, Hughes JP. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials. 2007;28(2):182–91. doi: 10.1016/j.cct.2006.05.007.
    1. Statistics Canada. Complete cumulative profile including Income and earnings, and shelter costs for Canada, provinces, territories and forward sortation areas, 2006 census. Statistics Canada. 2006. . Accessed 7 May 2015.
    1. Statistics Canada. Postal Code Conversion File (PCCF), reference guide (92-153-G). Statistics Canada. 2011. . Accessed 13 Feb 2015.
    1. Solomon DH, Brookhart MA, Gandhi TK, Karson A, Gharib S, Orav EJ, et al. Adherence with osteoporosis practice guidelines: a multilevel analysis of patient, physician, and practice setting characteristics. Am J Med. 2004;117(12):919–24. doi: 10.1016/j.amjmed.2004.06.040.
    1. Urkin J, Allenbogen M, Friger M, Vinker S, Reuveni H, Elhayani A. Acute pharyngitis: low adherence to guidelines highlights need for greater flexibility in managing paediatric cases. Acta Paediatr. 2013;102(11):1075–80.
    1. Frijling BD, Lobo CM, Hulscher ME, Akkermans RP, van Drenth BB, Prins A, et al. Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice. Qual Saf Health Care. 2003;12(3):181–7. doi: 10.1136/qhc.12.3.181.
    1. Lobo CM, Frijling BD, Hulscher ME, Bernsen R, Braspenning JC, Grol RP, et al. Improving quality of organizing cardiovascular preventive care in general practice by outreach visitors: a randomized controlled trial. Prev Med. 2002;35(5):422–9. doi: 10.1006/pmed.2002.1095.
    1. Frijling B, Hulscher ME, van Leest LA, Braspenning JC, van den Hoogen H, Drenthen AJ, et al. Multifaceted support to improve preventive cardiovascular care: a nationwide, controlled trial in general practice. Br J Gen Pract. 2003;53(497):934–41.
    1. Aspy CB, Enright M, Halstead L, Mold JW, Oklahoma Physicians Resource/Research Network Improving mammography screening using best practices and practice enhancement assistants: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21(4):326–33. doi: 10.3122/jabfm.2008.04.070060.
    1. Lemelin J, Hogg W, Baskerville N. Evidence to action: a tailored multifaceted approach to changing family physician practice patterns and improving preventive care. CMAJ. 2001;164(6):757–63.
    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. Gillam SJ, Siriwardena AN, Steel N. Pay-for-performance in the United Kingdom: impact of the Quality and Outcomes Framework-a systematic review. Ann Fam Med. 2012;10:461–8. doi: 10.1370/afm.1377.
    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):S33–44. doi: 10.1370/afm.1119.
    1. Manca DP, Greiver M, Carroll JC, Salvalaggio G, Cave A, Rogers J, et al. Finding a BETTER way: a qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice. BMC Fam Pract. 2014;15:66. doi: 10.1186/1471-2296-15-66.
    1. Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012;345:e5205. doi: 10.1136/bmj.e5205.
    1. Ferreira-Gonzalez I, Busse JW, Heels-Ansdell D, Montori VM, Akl EA, Bryant DM, et al. Problems with use of composite end points in cardiovascular trials: systematic review of randomized controlled trials. BMJ. 2007;334(7597):786. doi: 10.1136/.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera